plan of treatment - angels in waiting of treatment sample -2.docx · web viewmanual plan of...

Medi-Cal In-Home Operations Section Enclosure 5AHome- and Community-Based Services (HCBS)

Manual Plan of Treatment (POT)

1. PARTICIPANT INFORMATION

Name: Childs Name CIN: DOB: M FX Last First

Address:

Phone #: ( 909 ) 336-1958

Lake Arrowhead CA 92352Area code

City State Zip code

Medical Record #:

Medi-Cal # Primary Caregiver:

You

(Applicable for providers who use Medical Record #’s)

Relationship to Participant:

Nurse-Foster Provider

Primary Language:

English

2. PROVIDER INFORMATION

Name: Your Name Title: RN / LVN

Address:

Phone #:Area code

City State Zip

Provider #: NPI # FAX #:Area code

Start of Care Date:

*Treatment Period: 1st POT is 90 days only

(May cover up to 180 days maximum)

FROM TO:

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In-Home Operations Section Enclosure 5AHome- and Community-Based ServicesManual Plan of Treatment (POT)Participant’s Name:

Treatment Period:FROM TO

3. PRIMARY CARE PHYSICIAN

Name

Address:

Phone #:Area code

City State Zip code

FAX #:Area code

*Note: The treatment period may be less than the 180 days depending upon the licensure or certification requirements of the rendering provider.

4. MEDICAL INFORMATION – Include ICD-9 Codes where appropriate.Please add additional pages as needed.

Liver Transplant V42.7 Date of onset: 01/23/11Primary Diagnosis ICD-9

Coccidiomycosis disseminated 114.3 Date of onset:Exact date unknown

Secondary Diagnosis ICD-9

Hepatic Artery Thrombosis / Stenosis 444.89 Date of onset:06/25/11

Other Diagnosis ICD-9

Acute rejection of Liver Transplant 996.82 Date of onset:05/12/1403/2013

Other Diagnosis ICD-9Parents & Prior Foster Care CaregiversNoncompliance with medical treatment V15.81 Date of onset:

05/12/14 03/2013

Prognosis: Excellent Good X Fair Poor

5. MEDI-CAL HOME- AND COMMUNITY-BASED PROGRAMPlease check all that apply.

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Nursing Facility/Acute Hospital (NF/AH) Waiver

X In-Home Operations (IHO) Non-Waiver

6. LEVEL OF CARE (LOC)Please check only one.

NOTE: The LOC determination will be made by the Medi-Cal In-Home Operations Section and provided to the HCBS provider

once determined.

Acute ICF/DDH NF B (DP)

Adult Subacute ICF/DDN Pediatric Subacute, non-ventilator dependent

ICF/DD NF A Pediatric Subacute, ventilator dependent

X NF B

7. WAIVER-SPECIFIC SERVICESPlease check all that apply and enter the appropriate Frequency Key Code.

(Only complete if enrolled in an HCBS Waiver program.)

Service Frequency Key Code:D=Daily W=Weekly If other,Y=Yearly M=Monthly please describe below.O=Other

Case Management

Environmental Accessibility Adaptations

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Family Training

Personal Emergency Response Systems

Private Duty/Individual/Shared Nursing Care

Certified Home Health Aide Services

Respite

Medical Equipment Operating Expense

Waiver Personal Care Services

Community Transition Services

Habilitation Services

Transitional Case Management

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8. NONWAIVER SERVICESInclude all applicable services and frequency. May include those services funded by Medi-Cal, Regional Centers, California Children’s Services, Independent Living Centers, In-Home Supportive Services, Department of Rehabilitation, Department of Mental Health, Private Insurance, and/or school-based services.

Examples include: Adult Day Health Care, Pediatric Day Health Care, Medical Therapy Program, Housing Referrals, Social Service Referrals, and Vocational Rehabilitation. Please add additional pages as needed.

As Per California’s New State Law, Chapter 490: Medically Fragile Foster Care Infants & Children Preferential Consideration is given to Nurses-Foster Providers under the EPSDT Supplemental Nursing Non-Wavier programs. See the Attached State Law Chapter 490 requirements pertain into the care of Medically Fragile Fosters Care Population, and Page 4 of the discharge summary.

IHO EPSDT RN Direct shift Care (NF-B) 7.65 hours daily /7 days weekly as per AB 1133/ Chapter 490 California New State Law. (see attachment R/T California New State Law 2014).

Psychiatric Therapist visits up to 4 hours/month.

Lab draws weekly and/or PRN to titrate Tacrolimus/Prograf levels to avoid toxicity from adverse drug interactions with Prograf and Diflucan toxic levels may occur and close monitoring of conditions and titers are warranted.

UCLA Infectious Disease & Liver Transplant Team meetings and assessments, via weekly /PRN lab results. Loma Linda Infectious Disease Team

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9. MEDICATION PLAN FOR HOME PROGRAMSpace for additional medications provided on .

Allergies: Benadryl Morphine Reaction (if known):

Anxiety, itching

Medication: Tacrolimus (Prograf ) Dose:

0.5mg Route:

PO Frequency

BID

Medication: Fluconazole (Diflucan)

Dose:

300 mg Route:

PO Frequency

Daily

Medication: Cholecalciferol Dose:

400 Units

Route:

PO Frequency

Daily

Medication: Enteric Coated Aspirin

Dose:

81mg Route:

PO Frequency

Daily

Medication: Ferrous Sulfate Dose:

325mg Route:

PO Frequency

Daily

Medication: Polyethylene Glyco Dose:

8.5g Route:

PO Frequency

Daily

Medication: SMP/TMP Bactrim/Septra

Dose:

8mg Route:

PO Frequency

PRN high imm suppression

Medication: Ibuprofen Suspension

Dose:

200mg Route:

PO Frequency

PRN /Temp

Medication: Dose:

Route:

Frequency

9a. ADDITIONAL MEDICATIONS

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Medication: Dose:

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Who gives the medications to the patient? Nurse-Foster Provider : Your Name

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10. NUTRITIONAL REQUIREMENTSPlease include type of diet, and method, amount, and frequency of feeding.

Diet for age. Assessment of feeding tolerance recommended due to late onset hepatic/liver thrombosis now with stenosis. Frequent assessment of feeding tolerance warranted and assessment upper quadrant pain, and or deferred shoulder and back pain.

11. TREATMENT PLAN FOR HOME PROGRAMInclude all needed services, frequency, and duration of services and provider(s) of service(s).

Space for additional orders provided on Page 8.

Angel is a 10 y.o. female, who has a history of a poor parental social situations and multiple failed foster care placements due to complex medical needs coupled with medical non-compliance issues. During the latest hospital admission UCLA requested Client to be place with a Nurse-Foster Provider as per California’s new state Law: AB1133/Chapter 490. (See Attachments).

History: Liver Transplant & Poor Medical Compliance Issues: Angel was originally transferred to UCLA on 1/23/13 in fulminate liver and renal failure, along with stage 4 encephalopy due to Tylenol toxicity, prognosis was physical demise, in less than 48 hours. This fact prompted the decision to expand donor criteria to include an ABO incompatible liver, with a potential high incident of organ (liver) rejection. To complicate the situation further, Angel’s parents and caregivers; including 2 foster care placements, fail to give her, her rejection medications and did not follow-up with schedule Liver & Transplant Team follow-up appointments. As a result she went to liver failure and acute organ rejection several times since her liver transplant. As a result of poor medical compliance, her liver displayed organ rejection, and a late onset of hepatic artery thrombosis detected on ultrasound and angiograms, with the development of marked stenosis; narrowing of the hepatic artery is noted and an concern for his Medical Team. As a result of the above history close monitoring and assessment for acute hepatic failure is warranted. S/S to assess for: Enlarge liver, bloating, rapid weight gain, cardiac arrhythmias, pitting edema, jaundice, abdominal pain, or deferred shoulder back pain, feeding intolerance. Frequently daily QID assessment is warranted.

Infectious Disease: Coccidiomycosis (Valley Fever) Involving Bilateral Lungs & Brain:Due to Angel’s parental poor social situation, after the transplant her parents was driving her around XXX County without a back car window contributing to her increase exposure to Valley Fever from the dust that was stirred up and entered the car’s back seat. Moreover, their non-compliances with medical treatments enhanced the wide-spread infection to her brain and through-out her lungs : Angel contracted Valley Fever /Coccidiomycosis that disseminated to her Brain and both lungs, this complicates and causes a very perplexed medical dilemma for Angels’s Liver & Transplants Team who had secured help from Infectious Disease Professors at UCLA. The team is face with trying to suppress Angel’s immune system enough so the poorly

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match liver does not go back into failure and rejection. However, not suppress the immune system to the degree the coccidiomycosis fungus proliferate and settle in other portions of the brain and/or other organs including her liver. The Nurse-Foster Provider needs to micro-manage and assess client for increase disseminated coccidiomycosis and assess the client for external coccidiomycosis rashes, skin and joint lesions that may need to be lanced and drained, and notified health care team Stat of any findings. Internal disseminated coccidiomycosis; lungs and brain may caused cognitive, speech, and learning impairment, with personality changes behavior changes needs to be assessed continually. Lungs: Auscultation of lung fields and assessments for decrease breath sounds, poor profusion, compromised chest compliance, pneumonia-like distress, increase oxygen needs, and when droplet isolation protocol needs to be initiated to prevent school contamination. Acute Assessment is warranted throughout the day due to this perplexed triad of medical issues.* If client shows any sings and symptoms of fl like occurrences A Stat Coccidiodes AB,CF Serum needs to be drawn to r/o proliferation and dissemination of Valley Fever fungus to other organs or increase colonization in the brain and/or lungs. Frequent MRI’s & CT Scans are warranted due to dissemination of Valley Fever In her Brain and all lung fields, MRI and CT Scan of the body is schedule for comparative studies once CCS give clearance. Estimated date for tests Mid-February.

Adverse Medication Reaction & Toxicity Documented With Angels’s Treatment Modality; When Tacrolimus / Prograf is used with an anti-fungal such as Fluconzole marked drug toxicity has occurred: weekly/PRN blood levels are drawn for this condition. The concern is the coccidiomycosis will proliferate to the brain and other organs but the drug toxicity in it self has major complications as well. Close monitoring of behaviors and physical assessment is warranted daily. As a result of Angel’s perplexed and complicated health condition with titrated medication needs, lab draws and their interpretations. Acute Assessment is warranted throughout the day due to this perplexed triad of issues.

Close monitoring and graphing of body weight and height, BMI is warranted due to the need to keep her titrated Tocrolimus and Fluconazole levels within therapeutic levels to address the immunosuppressant to a level that will prevent her liver from going into rejection but not high enough to cause her coccidiomycosis to proliferate. The coccidiomycosis has already disseminated to her brain and has proliferated throughout both lungs. Adjustment of his medication is imperative as she gains or losses weight.

Angel is a non-compliant medically fragile 9 y.o.female, who on a daily basis takes 7 medications to assist in controlling his poorly match liver transplant and his disseminated coccidiomycosis. These medications may be titrated weekly for increase adherence. All medications need to be administered and monitored for efficiency and therapeutic verses toxicity, By auscultation and acute nursing assessment of lung fields, breathing characteristics and client’s respiratory status. Along with monitoring for acute liver failure due to hepatic artery stenosis, ABO /poor Liver transplant match, and Coccidiomycosis found in the lungs and the left temporal lobe of the brain. Assessment of the medications for toxicity or poor delivery; spitting it out, etc., is also warranted.

Both, UCLA, LLUMC and Department of Children’s Protective Services requested skilled continual nursing/medical care for this medically fragile foster child to be placed with a Nurse-Foster Provender working under the EPSDT supplemental nursing program. This was considered to alleviate numerous hospital admissions that has been documented in the past, as well as prevent or mitigate any further

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deterioration to the client labile health conditions. Department Of Children and Family Services highlighted on their Placement papers: Liver Transplant Needs Consistent Medical Care (See attachments with POT)

MENTAL

Angel is schedule to see a therapist monthly for PTSD, Depression and Anxiety disorders and Gender Dysphoria .

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11a. TREATMENT PLAN FOR HOME PROGRAM – CONTINUEDADDENDUM

NEUROLOGICAL

Angel was given a Brain MRI on 10/21/14 to note any new coccidiomycosis /intracranial infections. Previously seen left temporal lesion has markedly improved with minimal residual enhancement. Due to the disseminated active infection of coccidiomycosis and immunosuppressant being given, Ongoing Neurological Assessment is Warranted. Assess cognitive ability, speech patterns, learning difficulty, gait changes, pupils changes, grip changes, Orientation to location, time etc: is warranted due to MRI finding and medical and medication toxicity possibility and/or history.

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12. FUNCTIONAL LIMITATIONSPlease describe functional limitations per the physician’s order within each category.

Please add additional pages, as needed.

X No limitations noted.

MOTOR: May include limitations with walking and/or gross motor movement.

No limitations noted.

SELF HELP: May include limitations with activities of daily living such as bathing, toileting, eating, and dressing.

Angel needs help with activities of daily living. All medications must be administered and its efficiency must be assessed by a nurse who is the caregiver because the client is non-compliant and will not take his medications if he is not closely observed.

No limitations noted.

COMMUNICATION/SENSORY: May include limitations with hearing, speech, and/or sight.

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Patient suffers from PTSD, anxiety, depression and gender dysphoria. Patient has difficulty expressing her wants or needs. She will withdraw and not communicate in multiple situations.

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13. ACTIVITIESInclude permitted activities per the physician’s order, such as up with assistance, complete bedrest,

up as tolerated, and/or use of adaptive equipment such as wheelchair, walker, etc.

No restrictions on activities.

No contact sports due to his liver transplant.

Safety precautions in use:

Seizure precautions

X Universal precautions

Other:

Rehabilitation Potential: Good X Fair Poor

14. MENTAL STATUS May include information related to behavior and/or cognition such as aggression, depression,

agitation, confusion, and developmental disabilities.

No limitations noted – oriented to name, date, place, and time.

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Patient suffers from PTSD, anxiety, depression and gender dysphoria. Patient has difficulty expressing her wants or needs. She will withdraw and not communicate in multiple situations, However, Angel has greatly improved in all of the above behaviors.

Angel’s was given a Brain MRI on 10/21/14 to note any new coccidiomycosis /intracranial infections. Previously seen left temporal lesion has markedly improved with minimal residual enhancement. Due to the disseminated active infection of coccidiomycosis and immunosuppressant being given, Ongoing Neurological Assessment is Warranted. Assess cognitive ability, speech patterns, learning difficulty, gait changes, pupils changes, grip changes, Orientation to location, time etc., is warranted due to MRI finding and medical and medication history. New baseline and comparative date will be obtained via MRI and CT scans with and without contrast, scheduled for 02/27/15, treatment modality will be based of the study finding and lab results.

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15. DURABLE MEDICAL EQUIPMENTInclude all types of equipment used, providers of equipment, and funding sources (if known).

TYPE PROVIDER NAME FUNDING SOURCE

16. MEDICAL SUPPLIESInclude all types of supplies used, providers of supplies, and funding sources (if known).

TYPE PROVIDER NAME FUNDING SOURCE

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17. THERAPIES/REFERRALSCheck all that apply. Please include the date the referral was made and the reason why.

If therapy is ongoing, please indicate the current progress/status in Section 20.

Physical TherapyDate Referral Reason

Occupational TherapyDate Referral Reason

Speech TherapyDate Referral Reason

Enterostomal TherapyDate Referral Reason

Medical Social WorkerDate Referral Reason

NutritionistDate Referral Reason

Other/List 11/13/14

.Psychologist Ruth Lester PTSD,,Gender Identity Issues

Date Referral Reason

Other/ListDate Referral Reason

Other/ListDate Referral Reason

18. TREATMENT GOALS/DISCHARGE PLAN

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Please check only one.

Upon completion of this treatment plan, the participant will be able to function independently and maintain himself/herself safely in the home setting.

X Upon completion of this treatment plan, the participant will continue to need: minimal moderate X maximu

mSupport to be maintained safely in the home setting.

Describe specific goals and discharge plan, as related to the identified needs

_To mitigate frequent hospital admissions, and prolong the further deteriorations of the patient’s lungs. ______________________________________________________________________________________________________________________________________________________________________________

19. TRAINING NEEDS FOR PARTICIPANT/FAMILY

X No training needs have been identified for the participant and/or the family during this treatment period.

Yes, there are training needs for the participant and/or the family during this treatment period.

(If the yes box is checked, please describe the training needs and name(s) of the provider(s).)

Please use additional pages as needed.

20. SUMMARY OF PARTICIPANT STATUS DURING THIS TREATMENT PERIOD

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Only need to do after the 90 days on you 2nd POT Lives in an EPSDT Nurse–Foster Provider, home placement. Medication levels have been in the therapeutic ranges. Valley Fever fungal spores; Coccidioides are elevated to disseminated levels, due to drug resistance to fungal medications, and past poor parental medical compliance. Currently the client is asymptomatic, but requires frequent acute skilled nursing assessment due to his elevated fungal levels. Angel is schedule for total body MRI and CT Scan to obtain a baseline and comparative studies, currently awaiting CCS clearance, Pt has had NO re-hospitalizations, due to medical staff being comfortable with the nursing assessment skills, of the Nurse-Foster Provider.

21. After completing, please obtain original signatures. Keep the original and mail a copy to the appropriate IHO Regional Office

attention to the Medi-Cal In-Home Operations assigned Nurse Case Manager.

Participant Signature Date

Primary Caregiver Signature (as applicable) Date

L Your Signature here 2/1/15

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Your MD Signature herePhysician Signature Date

Provider Signature Date








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plan of treatment - angels in waiting of treatment sample -2.docx · web viewmanual plan of...

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